EyeWorld Asia-Pacific December 2019 Issue

54 EWAP DECEMBER 2019 CORNEA 9 - 11 July 2020 Singapore Supported by: College of Ophthalmologists, Academy of Medicine, Singapore APACRS Phaco Essentials A Video & Didactic Course 11 July 2020, Saturday Top level experts will provide most up-to-date and comprehensive teaching on the various steps in phaco ranging from biometry to surgical steps. Expect a fast and furious session from top international surgeons. Look out for more information at www.apacrs-snec2020.org sutures in the cornea, which when removed had left scars on the cornea. The first graft remained clear for 2 years until the recurrence of corneal edema, which led to graft failure, necessitating a new corneal transplantation. The second surgery was carried out by a different surgeon, who mistook the scars on the cornea from the preplaced cardinal sutures as resulting from a full thickness, penetrating keratoplasty (PK), when in fact the patient had undergone DSAEK. The miscommunication of the patient’s clinical history and failure to identify DSAEK led to an error involving a second graft transplantation on top of the first one, instead of the removal of the failed initial DSAEK graft. “Interestingly, when the patient came to us, the cornea was clear,” Dr. Mallias said. “The first DSAEK graft was uncompromised for 2 years, then failed and should have been removed before another graft was transplanted. Because the next surgeon thought that the first corneal transplant was a full thickness graft, for this reason he did not remove the previously failed corneal graft, but just added a second one instead. Surprisingly, the cornea was clear, despite chronic edema, and a corneal thickness of 974 µm. Slit lamp images distinctly showed the borders of the first and second grafts. OCT images revealed the two DSAEK grafts very clearly, one on top of the other, as well as the host cornea. We could see the attachment of both grafts to the host cornea with a little bit of edema within the cornea in one area.” Glaucoma and corneal swelling that are associated with cataract surgery have both been noted to increase a patient’s chances of corneal graft rejection. In addition, graft rejection rates can increase with the number of corneal transplants an individual has received. Despite the patient’s complicated ocular history, with a number of conditions putting him at a greater risk of corneal failure, such as corneal scarring, chronic corneal edema, graft rejection from a previous transplant, cataract surgery complications, and two overlapping transplants, his cornea remained clear and the second graft was uncompromised. “The cornea was not cloudy despite the fact that the two DSAEK grafts were stuck on top of one another. This unusual case shows that the cornea can remain clear despite the fact that the corneal thickness was more than 970 µm. The take-home message is that when we practice medicine, we have to be very careful and use proper diagnostics. Surgeons need to identify such cases and differentiate an eye with PKP and one with a DSAEK in order to make the right choices for the patient,” Dr. Mallias said. EWAP Editors’ note: Dr. Mallias is director of Laser Plus Eye Institute, Athens, Greece, and declared no relevant financial interests.